X-Ray Rounds: (Plain) Radiographic Evaluation of the Shoulder

1. X-Ray Rounds: (Plain) Radiographic Evaluation of the Shoulder Garry W. K. Ho, M.D. Sports Medicine Fellow - VCU / Fairfax Family Practice December 2006

2. Anatomy • 3 Bones • Humerus • Scapula • Clavicle • 3 Joints • Glenohumeral • Acromioclavicular • Sternoclavicular • 1 “Articulation” • Scapulothoracic

3. Anatomy • Humerus • Head * • Anatomic neck • Surgical neck • Greater tubercle* • Lesser tubercle* • Intertubercular groove • Deltoid tuberosity • Shaft *

4. Anatomy • Scapula • Body • Ventral (Costal) surface • Dorsal surface • Borders • Superior • Lateral (Axillary) • Medial (Vertebral) • Angles • Superior • Inferior • Lateral (Head)

5. Anatomy • Scapula • Glenoid • Acromion • Coracoid • Subscapular fossa • Scapular spine • Supraspinatus fossa • Infraspinatus fossa • Great scapular notch • Suprascapular notch

6. Anatomy • Scapular “Y” (Lateral)

7. Anatomy • Clavicle • First bone to start ossification; last to finish • The only bony strut b/w UE and axial skeleton • Flat outer (lateral, acromial) third • Traps, Delt, AC / CC ligaments • Tubular medial (inner, sternal) third • Strongest in axial load • Middle third • Most vulnerable to Fx

8. Anatomy • Glenohumeral joint • Ball and socket • Purpose: placement of primary prehensile limb • Very mobile; majority (0-120°) of shoulder movement (0-180°) • Price: instability • 45% of all dislocations • Joint stability depends on multiple factors

9. Anatomy • Glenohumeral joint • Passive stability • Joint conformity • Vacuum effect of jt vol • Synovial fluid adhesion and cohesion • Scapular inclination • Glenoid labrum (50%) • Coracoid ligaments • CCL, CAL • Joint capsule • Glenohumeral ligaments • SGHL, MGHL, IGHLC • Bony restraints • Glenoid fossa, Acromion, Coracoid • Coracohumeral ligament

10. Anatomy • Glenohumeral joint • Active stability • Biceps (long head) • Rotator cuff • Pectoralis muscles, trapezius, serratus anterior, rhomboids, levator scapulae, etc. (NOT deltoid)

11. Anatomy • Acromioclavicular joint • Diarthrodial joint • Thin capsule • AC ligaments • Anterior, posterior, superior, inferior • Coracoacromial ligament • Coracoclavicular ligaments • Trapeziod ligament • Conoid ligament

12. Anatomy • Sternoclavicular joint • Diarthrodial joint • Joint capsule • Articular disk • Intraarticular disk ligament • Sternoclavicular ligaments • Anterior, posterior • Interclavicular ligament

13. Anatomy • Coordinated shoulder motion • Glenohumeral motion • Acromioclavicular motion • Sternoclavicular motion • Scapulothoracic motion Scapular-humeral rhythm

14. AP View of the Shoulder • “Transthoracic,” or “Routine” AP View • AP relative to thorax • Suboptimal view of Glenohumeral joint • Good view of AC joint • “Scapular,” “Grashey,” or “Glenohumeral” AP View • Better visualize bony relationships incl GH joint • Suboptimal view of AC joint • Both have been called “True” AP Views

15. AP View of the Shoulder • “Routine” AP View • Clavicle • Scapula • Acromion & scapular spine • Coracoid • Borders & angles • AC & SC joints • Glenoid • Both ant & post lips • May obscure HH • Humerus • Head & necks • Gr & Lsr tuberosities

16. AP View of the Shoulder • “Glenohumeral,” “Grashey,” or “Scapular” AP View • Same structures • AC joint not visualized as well • Better visualize the glenoid & humeral head (especially with ER view)

17. AP View of the Shoulder

18. AP View of the Shoulder • AP View in External Rotation • Greater tuberosity & soft tissues profiled and better visualized • Best w/ Scapular AP • AP View in Internal Rotation • May demonstrate Hill-Sachs lesions • GH instability • Best w/ Routine AP

19. Which AP view should I get? • Routine AP with humeral head in internal rotation (IR) • Scapular / Glenohumeral AP with humeral head in external rotation (ER) Harding WG, Nowicki KD. Plane talk about shoulder radiographs. Phys Sportsmed 1998; 26(2)

20. Transthoracic Lateral View of the Shoulder • Not usually done • Not as useful • Many obscuring over- and underlying structures

21. Axillary Lateral View of the Shoulder • Good view of anterior-posterior relationship of GH joint • Coracoid • Acromion • Humerus • Glenoid • GH joint

22. Axillary Lateral View of the Shoulder • Alternate Axillary views 45° Velpeau View – magnified axillary view

23. Scapular “Y” Lateral View of the Shoulder • Relationship b/w humeral head and glenoid • Acromion • Coracoid • Scapular body • Scapular spine

24. Scapular “Y” Lateral View of the Shoulder • Scapular outlet view • A variation of scapular Y view • Same projection, but with beam tilted 5-10° caudad • Shoulder impingement: to evaluate the subacromial space and the supraspinatus outlet

25. Other Views of the Shoulder

26. Indications • American College of Radiology (ACR) Appropriateness Criteria for Musculoskeletal Imaging in Shoulder Trauma • Developed in 1995, revised in 2005 • AP with IR & ER, and lateral (axillary or scapular Y) views recommended for: • R/O fracture or dislocation • Subacute (~3 months) shoulder pain suspicious for: • Bursitis / tendonitis • RTC tear or impingement (as initial study)

27. Indications • Stevenson and Trojian: JFP in July 2002 • No definitive studies on the needs of shoulder radiographs have been done • Recommended obtaining plain films for: • Decreased ROM (especially: abduction < 90°) • Severe pain • History of trauma • Glenohumeral AP, outlet & axillary lateral views • Add AP with IR & ER in cases of trauma • AC joint views for suspected AC joint disease • Neck, chest, abdominal imaging for suspected referred pain Stevenson JH, Trojian T. Applied evidence: evaluation of shoulder pain. J Fam Pract 2002; 51(7):605-611.

28. Indications • Other indications • Suspicion of instability • Weakness of shoulder motions • The patient cannot communicate (altered mental status, alcohol intoxication, or other) • Persistent pain and decreased ROM • Anytime your history and physical don’t give you enough information

29. Normal routine AP in IR Normal routine AP in ER Normal axillary view

30. Routine AP and axillary views Neer classification 3-part proximal humerus fracture involving: - Surgical neck - Lsr tuberosity Tx: surgical eval

31. Proximal Humerus Fractures:Neer Classification • 2-part fractures • May be Tx’d conservatively if: • Displaced < 1 cm • Angulation < 45 ° • No dislocations • Good reduction • No intraarticular involvement • Anatomic neck intact • Otherwise: surgical evaluation • All else: surgical evaluation

33. Routine AP in ER, axillary, & scapular Y views Anterior-inferior dislocation No fracture Tx: Conservative

34. Routine AP in ER, axillary, & scapular Y views Bulb sign, rim sign, loss of parallelism Posterior dislocation; No fracture Tx: Conservative

35. Post-reduction AP film Routine AP view Inferior GH dislocation (Luxatio erecta) - Rare Tx: may attempt CR

36. Routine AP in IR and axillary lateral views No dislocation + concave osseous impression in postero-lateral aspect of humeral head What is this lesion called? Hill-Sachs lesion Tx: conservative vs. operative

37. Hill-Sachs Lesions

38. Bankart Lesions

39. Type I: conservative tx Type II: conservative tx Type III: conservative tx for most; may consider surgery for active heavy laborers, frequent overhead activity, athletes 20-25 y/o Type IV-VI: surgery Type III AC separation Tx: conservative mostly

40. Clavicle Fractures • Mostly conservative treatment • Consider surgery for: • Group II Fx’s (esp if medial to CCL) • Open fractures • Neurovascular compromise • Severe associated injuries • E.g. flail chest, mult rib fx’s, scapulothoracic dissociation • Nonunion / malunion

41. Scapular Fractures • Mostly conservative treatment • Surgical indications: • Controversial • Displaced intraarticular fx’s involving > 25% articular surface • Scapular neck Fx’s with • > 1 cm medial displaced • Angulation > 40 ° • Concomitant fx’s of clavicles, coracoid, acromion, scapular spine • Fracture-dislocations

42. Routine AP and Axillary Lateral Views Advanced L shoulder osteoarthritis Tx: Symptomatic relief PT / Rehab exercises Injections Consider surgical eval

43. Scapular Y views A: normal B: Fracture / anterior dislocation C: Posterior dislocation

44. Routine AP, “True” AP, and Axillary lateral views Split fracture of humeral head with dislocated GH joint Tx: Surgerize!

45. 34 y/o M with shoulder pn and “it feel like it wants to go out of socket” Glenohumeral AP & Scapular Y Lateral views of R shoulder Multiple radiodense loose bodies (largest infra coracoid & infra glenoid) Dx: Loose Bodies Tx: Surgical consult

46. Glenohumeral AP view of shoulder and humerus Radiolucent lesions spanning proximal third of L humerus Enchondromas Tx: Surgical consult (Biopsy)

47. Routine AP of R shoulder Group 2, type 2 R clavicle fracture Tx: Surgical repair

48. Glenohumeral AP, axillary lateral, and scapular Y views Normal findings Tx: as per clinical setting

49. Routine AP view Scapular body fracture Tx: mostly conservative

50. Routine AP view Proximal humeral shaft fracture Glenohumeral dislocation Tx: Orthopaedic consult